Mental Health and MS: Anxiety Disorders

In discussing aspects of mental health and multiple sclerosis, we have covered depression symptoms, depression causes, and depression treatments, mood swings and medication side-effects. Much has been written about MS and depression, but very little about MS and anxiety disorders, specifically panic disorder, obsessive compulsive disorder, and generalized anxiety disorder.

I found a fascinating article in the journal Multiple Sclerosis, Anxiety disorders and their clinical correlates in multiple sclerosis patients by M Korostil and A Feinstein (Multiple Sclerosis 2007; 13: 67-72), which sought to determine how common anxiety disorders are in patients with multiple sclerosis. The study was completed by collecting neurological and demographic data, as well as interviewing subjects and completing a battery of assessments, of 140 MS patients who attend a neurological outpatient clinic in Toronto, Canada.

Here is a summary the type of data collected:

Neurological information was gathered including disease course and duration, the presence of exacerbations, the use of disease modifying treatments and a measure of physical disability using the Expanded Disability Status Scale (EDSS).

All subjects were interviewed in-depth (using SCID-IV) to determine current and lifetime diagnoses of mental illness.

Lifetime suicidal intent and attempts were assessed using the self-harm question from the SCID-IV, and three self-report questions derived from the Beck Suicide Scale (BSS).

The interviews were supplemented with a self-report questionnaire, the Hospital Anxiety and Depression Scale (HADS). This scale, developed specifically for use with medically ill patients, minimizes the somatic symptoms of anxiety and depression and consists of seven questions pertaining to depression and seven to anxiety.

Psychosocial stressors were assessed in the following areas: work, finances, housing, marriage/relationships, friendships, and family supports.

Within this sampling of patients, the lifetime prevalence of any anxiety disorder was 35.7% while lifetime prevalence is 23% in the general population. The prevalence of panic disorder was 10% (vs. 3.5%), obsessive compulsive disorder was 8.6% (vs. 2.5%), and generalized anxiety disorder was 18.6% (vs. 5.1%). Fourteen percent of the patients were experiencing an active anxiety disorder at the time of the study. Interestingly, phobias were seen less commonly as compared to the general population. The prevalence of social anxiety disorder was 7.8% (vs. 13.3%) and simple phobia type disorder was 10.8% (vs. 11.0%).

All these numbers can be dizzying but they show how much more common anxiety disorders are for patients living with multiple sclerosis than for members of the general population. Subjects in this study with an anxiety disorder were more likely to be female and have a history of depression, drink to excess, report higher social stress and less support, and have contemplated suicide. A small correlation was found between reports of high levels of social stress and generalized anxiety disorder

Are anxiety disorders being diagnosed and treated in MS patients?

Only 34% of those with an anxiety disorder had previously been given a documented psychiatric diagnosis. Some 28% of subjects with an anxiety disorder were given a diagnosis of an affective disorder (such as depression), while none were actually given a diagnosis of an anxiety disorder per se.

Patients with an anxiety disorder (whether diagnosed or not) were 2.5 times more likely to be taking an anti-anxiety medication, such as lorazepam (Ativan®), clonazepam (Klonopin®), diazepam (Valium®), or alprazolam (Xanax®). However, 52% of patients with a diagnosable anxiety disorder were receiving neither an anti-anxiety medication nor psychotherapy. The diagnosis of an anxiety disorder had been missed in the majority of subjects, and therefore, they had not received treatment.

Conclusion

Anxiety disorders are common in patients with MS, but are frequently overlooked and under-treated. Risk factors include being female, a co-morbid diagnosis of depression, and limited social support. Clinicians should evaluate all MS subjects for anxiety disorders, as they represent a treatable cause of disability in multiple sclerosis.

The authors of the study point out that anxiety co-morbid with depression in a general psychiatric setting has been shown to worsen overall outcome. This combination often complicates anti-depressant treatment by requiring higher dosages for a longer duration and, at times, supplementary or different pharmacotherapy. Finally, I should point out that anxiety and alcohol abuse further complicate the issue and should be watched carefully by both the patient and his/her physician.

My Suggestion

If you are experiencing symptoms of anxiety or depression, please, please talk to your doctor. These treatable disorders are much more common in patients living with MS than in the general population and can easily be overlooked by doctors and neurologists.

Speak up for yourself. Be your own advocate. Please take care of yourself.